Search

BackgroundDetermining the humoral immunogenicity of tozinameran (BNT162b2) vaccine in patients requiring chronic renal replacement therapy, and its impact on COVID-19 morbidity several months after vaccination, will guide risk assessment and subsequent changes in vaccination policy.MethodsIn a prospective post-vaccination cohort study with up to 5 months follow-up we studied outpatient dialysis and kidney transplant patients and respective healthcare teams. Outcomes were anti S1/S2 antibody response to vaccine or infection and infection rate during followup.Results175 dialysis patients (40% women, 65±15 years), 252 kidney transplant patients (33% women, 54±14 years) and 71 controls (65% women, 44±14 years) were followed. Three months or longer after vaccination we detected anti S1/S2 IgG antibodies in 80% of dialysis patients, 44% of transplant recipients and 100% of controls, whereas respective rates after infection were 94%, 75% and 100%. Predictors of non-response were older age, diabetes, history of cancer, lower lymphocyte count and lower vitamin-D levels. Factors associated with lower titers in dialysis patients were modality (hemodialysis vs peritoneal) and high serum ferritin levels. In transplant patients, hypertension and higher calcineurin or mTOR inhibitor drug levels were linked with diminished antibody response. Vaccination associated with fewer subsequent infections (HR=0.23, p10titer (pConclusionsDialysis patients, and more so kidney transplant recipients, mounted reduced antibody response to COVID-19 mRNA vaccination, and lesser humoral response associated with more infections. Measures to identify and protect non-responsive patients are urgently required.SignificanceReports on the humoral immunogenicity of SARS-CoV-2 mRNA vaccines in patients with end stage renal disease are scarce, and association with subsequent COVID-19 morbidity is unknown. In this cohort study that included 175 patients treated with dialysis, 252 kidney transplant recipients and 71 control volunteers, the proportion achieving an antibody response was time- and group-dependent, reaching 80%, 44% and 100% at 3 months post prime inoculation. Personal history of vaccination, positive antibody responses and antibody titers associated with significantly lower risk of COVID-19 infection. Thus, in patients with end stage renal disease, SARS-CoV-2 antibody testing may be warranted after vaccination, to identify non-responders at higher risk for disease.

Sleeve gastrectomy (SG) is an effective treatment for extreme obesity; however, long-term weight loss outcomes remain largely understudied. We aimed to examine the long-term weight changes following SG and patient characteristics and lifestyle patterns related to weight loss outcomes. Data from medical records of patients operated in a tertiary university medical center between 2008 and 2014 were reviewed, along with information derived from a telephone questionnaire. Information included the following: current medical status, medications, side effects, behavior, lifestyle habits, and weight changes. A total of 212 patients (69.3% females) were included, with a median follow-up duration of 8 years post-SG. Mean age and baseline body mass index (BMI) of participants were 39.7 ± 12.0 years and 42.2 ± 4.9 kg/m2, respectively. Mean BMI, percentage excess weight loss, and percentage total body weight loss were 33.1 ± 6.1, 55.5 ± 27.5%, and 21.7 ± 10.7%, respectively. Higher baseline BMI was found to be the strongest independent predictor for insufficient weight loss (OR = 0.90, P = 0.001, 95% CI 0.85, 0.96). Sweetened beverage intake, usage of psychiatric medications, higher initial BMI, and lower age were significant predictors for increased weight gain from nadir weight (P

The appropriate strategies to minimize skeletal deterioration following bariatric surgeries are inconclusive. This randomized controlled trial evaluated the effect of preoperative vitamin supplementation on bone mineral density (BMD) and biochemical parameters in females post-sleeve gastrectomy (SG). Participants were randomized to a 2-month preoperative treatment with a multivitamin and vitamin D 4000 IU/d (intervention arm) or 1200 IU/d (control arm). Preoperative and 12-month postoperative follow-up evaluations included anthropometrics, biochemical parameters, and dual energy X-ray absorptiometry (DEXA). Sixty-two females (median age 29.7 years and median BMI 43.4 kg/m2) were recruited, 87% completed the 12-month follow-up. For the intervention and control arms, significant and similar reductions at 12-months post-surgery were observed in BMD of the hip (−6.8 ± 3.7% vs. −6.0 ± 3.6%; P = 0.646) and of the femoral neck (−7.1 ± 5.8% vs. −7.2 ± 5.5%; P = 0.973). For the intervention compared to the control arm, the 25 hydroxyvitamin D (25(OH)D) increment was greater after 2 months treatment, and vitamin D deficiency rates were lower at 3 and 6-months follow-up (P 0.339). Predictors for BMD decline in the total hip were the percentage of excess weight-loss, age>50 years, and lower initial BMI (P ≤ 0.003). SG was associated with a significant decline in BMD of the hip and femoral neck in young and middle-aged women, and was unaffected by preoperative vitamin D supplementation. Females who are peri-menopausal or with greater postoperative weight-loss should be particularly followed for BMD decline.

The role of angioembolization in managing hemodynamically stable patients with liver injury has obviated the need for surgery. Although mortality and morbidity rates after the adoption of this technique have decreased, this procedure is not devoid of complications. This study assesses the impact of this procedure and its associated complications. We performed a case series analysis of patients with hepatic trauma in a level one trauma center over 10 years (2008–2017). Data were collected from hospital records of patients with liver injury and analyzed according to demographics, injury type, management strategy, procedure time, efficacy, complications of embolization, and outcome. We included all patients who underwent angioembolization. Patients who underwent surgery only or had incomplete records were excluded. Of 366 patients with liver trauma, eighteen were managed with angioembolization. Of which, thirteen had grade IV injury or higher, while five had grade II or III. Twelve patients had blunt liver trauma. Six patients were initially managed by laparotomy followed by angioembolization. The most common embolized artery was the right hepatic artery (eleven patients). Nine patients had at least one complication after the procedure. The liver collection was the most common complication (seven patients). There was one hepatic complication-related death. Morbidity was more common in patients who underwent exploratory laparotomy before angioembolization compared to angioembolization alone. Those who had a laparotomy before the angioembolization may have a higher complication rate.

Food addiction and binge eating are common among individuals with obesity. However, a paucity of studies prospectively examined the prevalence and implications of food addiction before and post-bariatric surgery. We aimed to examine the prevalence of food addiction and binge eating before and after sleeve gastrectomy (SG) and to assess their associations with behavioral and weight loss outcomes. We followed at 3 (M3), 6 (M6), and 12 (M12) months postoperative, 54 women who underwent SG. Data collected including anthropometrics, nutritional intake, food tolerance, and physical activity measures. The Yale Food Addiction Scale and the Binge Eating Scale were used to characterize food addiction and binge eating, respectively. The mean baseline age and BMI were 32.1 ± 11.1 years and 44.9 ± 4.9 kg/m2, respectively. Pre-surgery, food addiction, and binge eating were identified in 40.7% and 48.1% of patients, respectively. The prevalence of food addiction decreased significantly up to M6, but increased to 29.3% at M12. The prevalence of binge eating decreased significantly through the follow-up up to 17.4% at M12. Those who met criteria for food addiction at M12 achieved significantly lower excess weight loss at M12 compared with those not meeting this criterion (P = 0.005). Food addiction scores at M12 negatively correlated with weekly physical activity (r = − 0.559; P

Small bowel obstruction is an uncommon disease in pregnant women and rare when it is caused by intussusception. Intussusception is a rare cause of intestinal obstruction in adult. When it occurs, it is almost always secondary to an underlying pathology acting as a lead point for invagination, such as polyps, hemartomas, lipomas, leiomyomas, Meckel's diverticulum, adenomas, strictures, and malignancies. Ectopic pancreatic tissue is a very rare pathology acting as the lead point. In this case, we present a very rare case of intussusception in a young pregnant woman, caused by an intramural ectopic pancreatic tissue in the ileum.

To evaluate the outcomes, weight loss predictors, and gastrointestinal symptoms of patients after laparoscopic sleeve gastrectomy (LSG). The postoperative medical status of the patients was obtained retrospectively using a questionnaire and was compared to existing medical data before the surgery. We included 201 candidates, 178 patients completed mean of 3 years of follow-up. Mean excess body weight loss (%EWL) was 65.14% ± 15.74 at 6 months, 78.53% ± 20.28 at 12 months, and 74.32% ± 23.92 at 3 years after LSG. Older age (P = 0.018), higher baseline BMI (P = 0.003), and higher number of medications (P

The beneficial effect of bariatric surgery (BS) in type 2 diabetes mellitus patients is well established. Conversely, little is known about the efficacy of BS in type 1 diabetes mellitus (T1DM) patients, despite the increasing prevalence of obesity in this population. A retrospective review was carried out on a prospectively collected bariatric surgery registry of all patients undergoing BS at two university hospitals between 2010 and 2015. Patients with T1DM were identified, and detailed chart reviews were obtained. In this time period, we operated on thirteen patients with T1DM. Eight were female (61.5 %). Median age at time of surgery was 38 ± 8.3 (range 28–53) years. The procedures performed were laparoscopic sleeve gastrectomy (n = 10) and laparoscopic Roux-en-Y gastric bypass (n = 3). On median postoperative follow-up of 24 (range 2.5–51) months, mean body mass index significantly decreased from 39.9 ± 4.1 to 30.1 ± 3.9 kg/m2 (P

Laparoscopic mesh repair has become an increasingly common method for repairing incisional hernias. The current method for fixating mesh to the abdominal wall includes tacking the mesh to the peritoneum and fascia and suturing the mesh to the fascia with trans-fascial sutures. The iMESH Stitcher™ is a stitching device developed to both simplify and expedite this procedure by passing the suture from one arm of the iMESH stitcher™ to the other. The device enables a stitch to be created in three quick moves using only one hand. We compared both the efficacy and procedure time of trans-fascial mesh fixation when performed with the iMESH stitcher™ as compared to the standard suture passer method. A mesh patch was installed on the internal abdominal wall of two pigs. Surgical residents and Medical students were participants in the study and were trained in both techniques. Each participant was asked to perform six fixations with each technique. The procedural time required for both fixation techniques was recorded. Participants were asked to assess subjectively the relative difficulty of each technique on a scale of 1–10 (10 = most difficult). Sixteen residents and students performed a total of 12 mesh fixations, each performing 6 fixations with each technique. Average mesh fixation suture time using the suture passer technique was 44 s for residents and 47 s for students. Average fixation suture time using the iMESH stitcherTM was 17 s for residents and 15 s for students. The average difficulty score for the suture passer technique was 6.1 as compared to 2.9 with iMESH stitcher™. Trans-fascial fixation with the iMESH Stitcher™ took significantly less time than the standard suture passer method. The iMESH Stitcher™ significantly simplifies the procedure of transfascial fixation and potentially reduces technical difficulties.

Since its introduction approximately 20 years ago, laparoscopic cholecystectomy has rapidly become the treatment of choice for symptomatic cholelithiasis [1–3]. Conventional laparoscopic cholecystectomy generally is performed through four small incisions in the abdominal wall [4]. In recent years, a less invasive method has been sought in an effort to reduce postoperative pain and morbidities such as wound infection and trocar-site hernias while further enhancing the cosmetic results. Initial attempts to perform the procedure through three and then two ports or with reduced-diameter trocars (needlescopic surgery) [5–9] have since been superseded by even less invasive and more innovative techniques, namely, single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) [10–13]. Single-incision laparoscopic surgery is an attractive technique for cholecystectomy due to its superior cosmetic results and potential to reduce the rate of wound complications such as infection, hematoma, and hernia. This technique, however, is not straightforward. The technical complexity of SILS naturally results in a steep learning curve and increased operating room time and requires specialized equipment. The primary technical obstacles of SILS currently include Collision of instruments both within and outside the abdomen as a result of their common entry point (“sword fighting”) Inadequate triangulation Compromised field of view due to obstruction by instruments entering the common port Inadequate exposure and retraction. Several techniques have since evolved to overcome these potential pitfalls [14–16]. By incorporating a number of these techniques, we have created a simplified technique that has proved successful with both animal and human subjects. We describe both our experience and what we have learned, which have allowed simplification of a technical complex procedure.

As the field of minimally invasive surgery continues to develop, surgeons are confronted with the challenge of performing conventional laparoscopic surgeries through fewer incisions while maintaining the same degree of safety and surgical efficiency. Most of these methods involve elimination of the ports previously designated for retraction. As a result, minimally invasive surgeons have been forced to develop minimally invasive and ingenious methods for providing adequate retraction for these procedures. Herein we present our experience using endoloops and internal retractors to provide retraction during Single Incision Minimally Invasive Surgery (SIMIS) and Natural Orifice Transluminal Endoscopic Surgery (NOTES) cholecystectomy. We also present a review of the alternative retraction methods currently being employed for these surgeries. SIMIS was performed on 20 patients and NOTES was performed on 5 patients at our institution. Endoloops or internal retractors were used to provide retraction for all SIMIS procedures. Internal retractors provided retraction for all NOTES procedures. Successful cholecystectomy was accomplished in all cases. One SIMIS surgery required conversion to standard laparoscopy due to complex anatomy. There were no intraoperative complications. Although adequate retraction was accomplished in all cases, the internal retractors were found to provide superior and more versatile retraction compared to that of endoloops. Adequate retraction greatly simplifies SIMIS and NOTES surgery. Endograb internal retractors were easy to use and were found to provide optimal retraction and exposure during these procedures without complications.

Gastro-intestinal stromal tumors (GISTs) of the appendix are a rare entity. To date, only a handful has been described in the literature, all of which have been of the benign type. We present the first reported case of a malignant appendiceal GIST. The tumor was discovered when the patient presented with a peri-appendiceal abscess which appeared suspicious on CT. The abscess was drained and managed medically. The patient responded to antibiotic treatment but subsequent CT and biopsy confirmed the diagnosis of appendiceal GIST, and the patient was started on treatment with imatinab mesylate. One week after initiation of therapy, the patient returned with frank peritonitis necessitating surgery. Abdominal exploration revealed an appendiceal GIST locally invading and perforating adjacent bowel. We describe the complex presentation and course of the case as well as a literature review of the appendiceal GISTs and the current approach to treatment.

NOTES cholecystectomy, may eliminate complications related to abdominal incisions. However, the nonmandatory gastrotomy and its safe closure is the main controversy accompanying this approach. Transvaginal access has minimal closure consequences but the safety of inserting extralong instruments between the intestines and having the angle of approach from below rather than from above is questionable. We conducted a study for performing cholecystectomy using a single laparoscopic trocar.The single-trocar cholecystectomy technique was developed on five porcine animal models weighing 35-40 kg each. A 15-mm trocar was used, inserted transumbilicaly. Retraction of the gallbladder was achieved using an endoloop and transabdominal anchoring. Hartman's pouch was manipulated with an endoscopic grasper, which was passed through the working channel of the endoscope, while dissection of the triangle of Callot was performed using articulating laparoscopic instruments.Single-trocar cholecystectomy was successfully performed in four of five porcine models. Average surgery time was 90 min (35-180 min). The technique was modified and improved throughout the study. No intraoperative complications occurred.Single-trocar cholecystectomy is feasible and offers safe approach to this procedure. We assume that a single incision at the umbilicus generates minimal somatic pain, and achieves excellent cosmetic results. The translation of this technique to human subjects seems straightforward and raises the question of whether NOTES is the preferred technique for cholecystectomy.

The azygos vein is of superior importance during the operation for esophageal atresia with tracheo-esophageal fistula (EA; TEF). Its location helps the surgeon to locate the fistula. Newborns with persistent left superior vena cava (LSVC) may have alterations in the location of the azygos, and since LSVC is not uncommon in EAs with fistulae, it is important to locate the azygos during a pre-operative echocardiogram. Foreknowledge of a possible absent azygos may avoid morbidity while trying to locate the fistula. We present a case of a newborn with EA, TEF, and LSVC in which the azygos vein was absent.